Atypical antipsychotics for older adults: are they safe and effective as we once thought?

The initial enthusiasm for atypical antipsychotics as being safe and effective for treating older adults with psychotic disorders has diminished. Despite multiple short-term double-blind trials, these drugs have not been approved by the FDA for the most common form of psychosis in this population – i.e., psychosis associated with dementia. On the contrary, these drugs have received FDA warnings for adverse cerebrovascular events and mortality in these patients. Our pragmatic clinical trial failed to show evidence of either safety or effectiveness of the four most commonly prescribed atypical antipsychotics in middle-aged and older patients with different psychotic disorders – schizophrenia as well as psychosis associated with mood disorders, dementia or PTSD. A reconsideration of the common use of these medications, especially off-label use, in older patients is warranted. Unfortunately, there are no evidence-based alternatives to these agents in the target population. Wider employment of psychosocial interventions, cautious and limited use of medications, shared decision making, and greater research on developing better treatments are the order of the day.